02-031 C.M.R. ch. 420, § 4 - Definitions

A. "Adverse benefit trigger determination" means a claims denial determining that the insured has not satisfied a required clinical standard for benefit eligibility, including, when applicable under the contract, the existence or degree of cognitive impairment, chronic illness, or inability to perform one or more specified activities of daily living. The term is described more fully in Bureau of Insurance Rule 425, Sections 27 and 28.

B. "Authorized representative" means:

1. A person to whom an insured has given express written consent to represent the insured in a standard appeal or an external review;

2. A person authorized by law to provide consent to request in an internal appeal or an external review for an insured; or

3. A family member of an insured or an insured's treating health care professional when the insured is unable to provide consent to request an internal appeal or an external review

C. "Bureau" means the Maine Bureau of Insurance.

D. "Claims denial" means any reduction of a benefit, termination of a benefit, or failure to provide or make payment (in whole or in part) for a benefit, including a determination of an insured's ineligibility for benefits. The term "claims denial"includes both clinical decisions and benefit determinations that do not involve clinical decisions.

E. "Claims denial eligible for external review" means an adverse benefit trigger determination or a claims denial that requires the exercise of professional judgment within the scope of practice of a health care professional on the applicability of the following policy limitations or exclusions:

1. A preexisting condition or disease;

2. Mental or nervous disorders;

3. Alcoholism and drug addiction;

4. Illness, medical condition or treatment arising from:

a. War or act of war (whether declared or undeclared);

b. Participation in a felony, riot or insurrection;

c. Service in the armed forces or units auxiliary thereto;

d. Suicide, attempted suicide or any intentionally self-inflicted injury; or

e. Aviation.

F. "Substantive issue" means a matter that is integral to the determination of whether the insured is eligible for benefits under a policy and that involves information essential for the insurer to have prior to paying the claim. A substantive issue includes the issues generated by the items described in Sections 9(A)(1) through 9(A)(5). A substantive issue also includes information necessary to pay the claim that the insurer is unable to obtain because the provider refuses to provide it or because it is not available from sources other than the insured or the insured's authorized representative.

G. "Technical issue" means a matter that is procedural in nature or not integral to the determination of whether the insured is entitled to benefits under the policy. Examples of a technical issue are an insurer's lack of receipt of completed forms that duplicate information that the insurer already has or the license number for a long-term care facility.

Notes

02-031 C.M.R. ch. 420, § 4